Referral for Domestic and Family Violence Support

Url

Referrer Details

First Name *

Last Name *

Email *

Phone *

Client Details

Client Consent Obtained

The client has consented to this referral and understands that their personal and sensitive information will be shared with LocalKind for the purpose of providing support services related to domestic and family violence. The client understands they can withdraw their consent at any time by contacting LocalKind.

Client's First Name *

Client's Last Name *

Client's Date of Birth *

Client's Gender *

DVSAT Score

Upload DVSAT or other document

DVSAT Comments and Reason for the Referral

Safe Communication Protocols

Add information about any safe communication protocols, e.g. don't use SMS or only communicate via SMS or use the client's work email

Safe times to contact the client

Monday mornings

Monday afternoons

Tuesday mornings

Tuesday afternoons

Wednesday mornings

Wednesday afternoons

Thursday mornings

Thursday afternoons

Friday mornings

Friday afternoons

Safe Phone Number

Safe Email Address

Collection Notice

Purpose of Collection: LocalKind collects the information provided in this referral form for the purpose of assessing client needs, providing appropriate support services related to domestic and family violence, and coordinating care with relevant agencies.

Information Collected: The information collected includes personal and sensitive information about the client, including but not limited to their contact details, demographics, family situation, and details about the experience of domestic and family violence.

Disclosure: This information will be shared with LocalKind staff involved in service delivery and may be shared with other relevant agencies involved in the client's care, only with the client's consent.

Storage and Security: LocalKind stores information securely in accordance with the organisation's privacy policy.

Access and Correction: Clients have the right to access and correct their personal information.

Contact: For any privacy-related enquiries, please contact LocalKind on 02 9977 1066 or info@localkind.org.au

Emergency and Crisis Numbers

Emergency Services

000

Call 000 if you are in danger.

Domestic Violence Line

1800 65 64 63

The NSW Domestic Violence Line is available 24/7.

Interpreters are available.

If you are hearing impaired, call the National Relay Service on 133 677.

facs.nsw.gov.au/domestic-violence/helpline

Lifeline

13 11 14

Lifeline has a national number that can help put you in contact with a crisis service in your State. Anyone across Australia experiencing a personal crisis or thinking about suicide can call lifeline

www.lifeline.org.au

Link2home

1800 152 152

Link2home is the statewide homelessness information and referral telephone service. It is available 24 hours a day, 7 days a week, every day of the year.

For information, assessment or referral to homelessness services and support in NSW, call Link2home.

www.facs.nsw.gov.au

LocalKind is part of the Northern Beaches Domestic Violence Network

You can find additional information about Northern Beaches Domestic Violence Network here.

You can also get help here from other services and resources in the Network.

For all other enquiries, please use this contact form below.

Web Site

First Name *

Email Address *

Last Name *

Mobile Number

Message *

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